How will you classify ACJ Dislocation? What structures are damaged at each stage?
Rockwood Classification - comparing the Coraco-clavicular distance to the contralateral normal side
Type 1: No displacement [ACJ sprain]
Type 2: < 25% displacement [ACJ torn and CC strain]
Type 3: 25-100% displacement [AC and CC torn]
Type 4: Posterior displacement
Type 5: > 100% superior displacement [Deltotrapezial fascia torn]
Type 6: Inferior displacement
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How to differentiate type 4 from other types?
An axillary view is needed to visualize posterior translation
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What special radiographs are needed?
Zanca view: 10Β° below horizontal in the plane of the clavicles
Bilateral clavicles on the same film to compare CC distances
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What are the absolute indications for surgery?
Types 4 and 6
Open fracture or neurovascular deficit
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What is the controversy in ACJ dislocation?
There is no consensus in the optimal treatment for high grade ACJ dislocation
Nicholas Chang et al. Meta-analysis in JOT 2018 found no clinical difference between op and non op for grades 3-5. Non op had more rapid RTW but poorer cosmetic outcome
Joukainen et al. in OJSM published a 20 year follow up of high grade ACJ in 25 patients. RCT op vs non op. Equally good clinical results but radiographically wider ACJ
In essence, it is replacing a bump for scar. I will discuss with the patient the pros and cons for the surgery and allow him to make an informed consent
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What are the surgical options for acute dislocation (< 6 weeks)?
The principle is to reduce the joint to allow scarring and healing of soft tissues
Multiple fixation techniques are available:
Hook plate
Pros: Biomechanically stronger construct
Cons: Acromiolysis, acromion fracture
Suspensory fixation
Pros: No need for removal, can be performed arthroscopically
Cons: Risk of coracoid fracture
Outcomes: Meta-analysis shows no difference in outcomes or complication rates, though types of complications differ